Medical Students' Attitudes Toward Physician-Assisted Suicide

Copyright 1999 American Medical Association. All Rights Reserved. Applicable FARS/DFARS Restrictions Apply to Government Use.1999American Medical AssociationThis is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Context In November 1994, Oregon became the first US state to legalize physician-assisted suicide (PAS) as an option for end-of-life care.

Objective This study compares the attitudes and experiences of medical students in Oregon regarding PAS to those of fourth-year medical students in the United States outside Oregon.

Design A survey of all students at the Oregon Health Sciences University and fourth-year medical students at 3 non-Oregonian US medical schools.

Participants Oregon medical students returned 227 questionnaires (58%), and 113 were returned from control schools (33%).

Results A similar percentage of both study groups favored the legalization of PAS (64% vs 66%; P = .74). If the practice were legal, 55% of the total surveyed reported they "might be willing to write a lethal prescription," (50% Oregon students vs 60% control; P = .13 and 44% fourth-year Oregon students vs 60% control; P = .04). Among fourth-year students, 20% reported a request by a patient to the student or a preceptor for a lethal prescription in the past year (26% vs 16%; P = .09).

Conclusions This study demonstrates support for and willingness by many medical students to participate in PAS. Some medical students reported observation of PAS during their training experience. Fourth-year Oregon students reported significantly less willingness than other students to provide a patient with a lethal prescription, perhaps indicating hesitancy to include PAS in clinical practice.

In 1994, Oregon became the first state to legalize physician-assisted suicide (PAS) with passage of the Oregon Death With Dignity Act1 and today remains the only US state in which PAS is legal. To assess the attitudes of Oregon physicians toward euthanasia and PAS, a questionnaire was developed by the Oregon Health Sciences University (OHSU) Center for Ethics in Health Care and sent to Oregon physicians in 1995.2 Results of this study demonstrated widespread support for the law, and since its passage many physicians have participated in PAS.3 Additional studies have consistently demonstrated that a large percentage of physicians support PAS.4-10 Most US medical schools now specifically address end-of-life care in their planned curriculum, and several organizations are developing and disseminating physician education programs to improve end-of-life care.

The current study compares the attitudes and experiences of Oregon medical students regarding PAS to a sample of non-Oregon US medical students. Additionally, fourth-year Oregon students were compared to first-, second-, and third-year Oregon students with less clinical experience. These comparisons demonstrate differences in attitudes that may exist between students who face a real possibility of providing PAS in the immediate future and students for whom PAS is less likely to be an issue in practice or is less commonly addressed in clinical experience.

Methods

Study Design

All students at the Oregon Health Sciences University, the only school of medicine in Oregon, received a previously developed, anonymous 54-item questionnaire2 in their campus mailbox. The same questionnaire was sent to fourth-year medical students at 3 other medical schools chosen through a stratified randomization process, 1 each from the midwestern, southeastern, and northeastern regions of the United States. This study design was chosen to compare the attitudes and experiences of students in a state in which PAS is legal to those of students in states in which PAS is not legal. Questionnaires were returned in provided, self-addressed, stamped envelopes. No incentive was offered for participation. OHSU students were given 3 formal, written reminders to increase response rate. Students at the control schools received only the initial envelope.

Survey Instrument

The questions included in this student questionnaire were similar to those in the original questionnaire2 and assessed basic demographic information, general attitudes toward PAS, and actual clinical experience with PAS issues. Two questions from the original questionnaire were excluded because they applied only to practicing physicians; several questions were edited to address students more appropriately. The OHSU Human Subjects Committee and the original questionnaire's authors approved the revised questionnaire.

Subjects

Participating schools approved student participation. Confidentiality was ensured by the use of an anonymous questionnaire returned in a sealed envelope. As envelopes arrived at the collection office, the signed consent form and questionnaire were immediately separated, and student participation was tracked by crossing each student's name off a class list using the signed consent form. The database therefore contained no markers identifying students.

Statistical Analysis

Data were analyzed using SPSS (Version 6.1, SPSS, Inc). Three study groups were identified: control students; OHSU fourth-year students; and OHSU first-, second-, and third-year students. Comparisons were all Oregon students vs non-Oregon students; fourth-year Oregon students vs controls; and fourth-year Oregon students vs first-, second-, and third-year Oregon students. Continuous variables were analyzed using t tests and categorical variables were analyzed with the χ2 test. Correction for multiple comparisons was not used.

Results

Sample Characteristics

Of the 399 questionnaires administered to Oregon students, 227 were returned (58%). Of the 340 questionnaires administered to control students, 113 were returned (33%). The final study group consisted of 51% male students with a median age of 28. All groups were similar in gender, specialty preference, religion, or experience in caring for terminally ill patients, but fourth-year Oregon students, compared to controls and first- through third-year Oregon students, were older and less likely to have attended high school in a large city (P = .02; P = .005). Compared to the control students, the combined group of Oregon students was younger (P<0.001), more likely to project entering primary care (P = .03), less likely to report any religious affiliation (P<.001), and reported less experience caring for terminally ill patients (P<.001).

Outcomes

Oregon and non-Oregon students were equally likely to find that PAS should be legal in some situations (P = .74) and if legal, 52% of students from Oregon (52% vs 60%) reported that they "might be willing to assist a patient by writing a lethal prescription." Fourth-year Oregon students were significantly less likely than non-Oregon fourth years to report a willingness to provide a patient with a lethal prescription (44% vs 60%; P = .04) and were also less likely to report this willingness than other Oregon students in earlier stages of medical school (44% vs 55%; P = .14).

More Oregon fourth-year students (26% vs 16%) reported a request by a patient in the previous year to themselves or their immediate preceptor for a lethal prescription (P = .09). Students from Oregon were equally as likely as controls to comply with these requests (P = .93).

Discussion

In this small sample, a large percentage of US medical students feel that PAS should be legal and report willingness to practice PAS, if it were legalized. Previous administration of this survey to Oregon physicians demonstrated that 60% felt that PAS should be legal in some cases,2 a figure similar to the 65% found for all medical students in this study. Interestingly, the group least willing to write a lethal prescription was fourth-year Oregon medical students (44%). This result is similar to that previously found for practicing Oregon physicians (46%)2 and much lower than this study's results for non-Oregon fourth-year medical students (60%) and younger Oregon students (55%). Nationwide, 36% of physicians would be willing to write a lethal prescription.4 The significant difference between fourth-year Oregon students and the other study groups may indicate that a change in willingness to comply occurs when a person is faced with actually writing lethal prescriptions. In addition, the "end-of-life" curriculum for Oregon students includes added emphasis on alternative approaches to end-of-life care, perhaps leading fourth-year Oregon students to believe that compliance with a request for PAS could be unnecessary.

Regarding requests for lethal prescriptions, 18% of physicians nationally3 and 21% of Oregon physicians have received such a request.2 These findings are similar to the 20% of fourth-year students in this sample reporting such a request, to either themselves or their immediate preceptor. Compliance with a request was observed by 6% of fourth-year medical students (of those reporting a request), comparable to the 7% among Oregon physicians2 (before passage of the ballot measure) and lower than the 16% found nationally.3 The finding that a similar percentage of US physicians receive requests for lethal prescriptions may be an indicator of similarity in the quality of end-of-life care provided throughout the United States or of similarity in patients' attitudes toward this option.

Limitations of this study include a low return rate and return bias. Return bias could have resulted because participating schools restricted the issuance of reminders. These restrictions also made it difficult to assess the number of students who actually received the survey. Because of the low response rate of the controls, these results might not be representative. Nonetheless, this study provides insight into the attitudes of some medical students toward PAS. More than 60% of medical students surveyed feel that PAS should be legal in some situations and comment that they would be willing to participate in this practice if it were legal.

Acknowledgment: We would like to acknowledge the OHSU Center for Ethics in Health Care for their work in the development of the questionnaire used in this study.